Recognition and Treatment of a Hidden Problem

North Bay Literacy Council – Literacy and Health Presentation

Funding for the Literacy & Health Project

This project is funded by the Ontario Trillium Foundation, from the Ministry of Culture

The project provides funding for one year (December 2006-2007)

One person for three days per week

Do you know?

Which of the following is the strongest predictors of an individual’s health status?

A) AgeB) IncomeC) Literacy skillsD) Education level E) Racial or ethnic groupF) Average Beer Intake at Metro

Do you know?

Which of the following is the strongest predictors of an individual’s health status?

A) AgeB) IncomeC) Literacy skillsD) Education level E) Racial or ethnic groupF) Average Beer Intake at Metro

True or False? Most people with limited literacy

have low IQs. People will tell you if they have

trouble reading. The number of years of schooling is

a good general guide to determine literacy level

Most people with low literacy skills are poor, immigrants or minorities.

Goals of the Presentation Recognize the scope and

implications of health literacy issues. Identify and implement strategies to

enhance patient understanding. Learn to evaluate health care

literature and documentation Referral process for clients who want

help in the community.

Health Literacy

Health literacy is the degree to which people are able to access, understand, appraise and communicate information to engage with the demands of different health contexts in order to promote and maintain good health across the life-course.

Types of Illiteracy Functional illiteracy Sensory/physical illiteracy Cultural/language illiteracy Psychological illiteracy Computational illiteracy

Functional Literacy Ability to read, write and speak in

English Compute and solve problems at

levels of proficiency necessary to function in society

Ability to achieve one’s goals and develop one’s knowledge and potential

Physical Literacy Sensory

Visual Hearing Neurological

Psychological / Mental Health Other physical

Metabolic Endocrine

Cultural/Language Non-English speaking Immigrant status Ethnic interpretation of illness Spiritual and religious beliefs Majority of the lowest level readers

are white and native born

Computational – Health Numeracy

The degree to which individuals have the capacity to access, process, interpret, communicate, and act on numerical, quantitative, graphical, biostatistical, and probabilistic health information needed to make effective health decisions

Computational Numeracy

The ability to count, quantify, compute, and otherwise use simple manipulation of numbers, quantities, items, or visual elements in a health context so as to function in everyday situations. An example would be using nutritional labels correctly

Analytical Numeracy

This involves the ability to make sense of information, as well as higher functions like inference, estimation, proportions, percentages, frequencies, and equivalent situations. Information may be from multiple sources, and an example would be determining whether an analytical result was within the normal range, or understanding graphs

Statistical Numeracy

An understanding of basic biostatistics involving probability statements, skills to compare different scales (Probability, proportion, percent), to critically analyze quantitative information like life expectancy or risk, and understanding concepts like randomization and blinding. An example would be making choices between treatments based on standard outcomes of relative or absolute risk

Scope of the Problem LBS (Literacy Basic Skills)- Level 1 22% of adult Canadians are so limited

that they are unable to determine the correct dosage from reading the medicine label.

LBS (Literacy Basic Skills)- Level 2 A further 26% can read provided that the

materials are simple and presented in a familiar context.

LBS – Literacy Basic Skills

There are five levels The levels provide a summary of

skills for each level of written, verbal innumeracy outcomes

It offers a common language to describe learner levels and outcomes

LBS- Level 1 Indicates very low literacy skills where the

individual may, for example have difficulty identifying the correct amount of medicine to give a child from the information found on the package. These individuals are generally aware they have a problem

LBS Level One Grade 1-2 Can

Sign name Find expiration date on license Total bank deposit entry

Can’t Use bus schedule, find intersection on map Fill out health history form Total costs on an order form Can’t read a simple story to a child

LBS Level 2 Respondents can deal with material that

is simple, clearly laid out and in which the tasks involved are not too complex. This is significant because it identifies people who may have adapted to everyday life, but would have difficulty learning new health related material and making informed decisions. These individuals often do not recognize their own limitations.

LBS Level Two Grade 2-3 Can

Find intersection on map Locate info in news article Tell difference in two ticket prices (compare

and contrast) Can’t

Use bus schedule Read a bar graph Write a letter of complaint

What Happens? Problems with: Navigating from one clinic to

another Completing forms Following medication instructions Interactions with providers Coping strategies in general

What Happens? Limited general knowledge (Health

promotion & prevention) Do not ask for clarification Focus on details, hard to get them to

prioritize Don’t understand Likert scales, math Deal in literal/concrete concepts, not

abstract Essential vocabulary only Check answers without understanding

Why worry?

Not keeping appointments—26% Unable to find clinic/office Failure to take meds correctly—42% did

not understand “empty stomach” Incomplete history Overuse of emergency room Lack of informed consent Diagnosis made at later stages Unhealthy/risky behaviors

More reasons More than 80% of Canadians over 65

have low literacy skills and are unable to cope with the demands of everyday life and work.

Seniors with low literacy are more likely to have health problems than seniors with high literacy abilities

Non compliance can be life threatening

The elderly Fewer years of schooling, poorer—fixed

incomes > 50% do not take meds as directed 68% cannot interpret blood sugar value 76% cannot follow Upper GI instructions 2 billion dollars spent per year on hospital

admission for medication errors

Oh, I can tell…Oh no you can't

If you can tell which patients are illiterate, you are doing better than trained physicians

Shame and stigma therefore… 67% have never told their spouses

and 19% never told anyone

More on Identifying Forgot their glasses Eyes wandering over page, very slow to

finish, sounding out words, look confused NEVER ask “How well do you read.” Response will be: - Feign anger- Walk out rather than admit it.- If a person acts out, be curious.

More on Identifying 98% will bring someone with them

who read. 88% will watch others or copy. 90% will ask for help from the staff(front desk person) 80% will ask for help from other

patients. Take forms home to complete

More on Identifying Read too slowly or too quickly Ask a lot of questions or none Frequently use health care system Routinely miss scheduled

appointments Never refer to written information

they have received Non-compliance with directions

Who Are They? Not stupid All social classes No racial/ethnic bias Amazing ability to function

Literacy Tests

Always assume and ask in sensitive way—”How do you like to get your information?” or “What things do you like to read?” or “How satisfied are you with how you read?” Treat all the same.

So, do I test them? Time/place/training Confidentiality and ethics Cost Reliability and validity Timing re: patient Age, sight, hearing, cognitive Language

What to do Whole staff must be aware and sensitive Speak slowly and start with context Quiet room with minimal distractions Use monosyllabic and colloquial terms—avoid

technical terms. Be concrete and use active voice.

Start with the most important information first and limit new information

No more than one or two instructions at a time—and check on each as you go: “Chunks and Checks”

More hints Use repetition Have the patient repeat the information Use the “teach back” method Never ask “Do you understand?” Use models, sketches, pictures, symbols

demonstrations Consider follow up phone calls Give instructions to several of family

members If you are rushed, get someone else to do

it

More interventions Know what languages and cultures you

will encounter in your community-know what resources you will need

Check the reading level of materials you give to patients

Consider referring your patient to the North Bay Literacy Council

Develop partnerships between the health and literacy sectors

Work with your schools to get health education into the K—12 curriculum

Printed Materials (Secondary to Verbal) Use pictures, photos, videos and other visuals—

including med charts Monosyllabic and simple language Read over the instructions—highlight important

parts with color Lots of white space Review materials for literacy level—rewrite as

necessary, ask patients for help Writing style should be clear, concise, organized,

and jargon-free

Assessing level of literature Most pamphlets at 10-12th grade

level Informed consents at 14.3—16th

grade level Internet health resources at similar

grade levels SMOG

Speaking Plainly Request and respect patients prior

knowledge, opinion and experience Speaking plainly is as important as writing

plainly Avoid jargon Use everyday examples to explain

technical or medical terms Teach in an organized manner Use the “interactive communication loop”

Legal issues Informed consent and living wills need

post-college level comprehension Must explain verbally as well as give

written—just handing them the form to sign is not informed consent

Legal right to understand alternatives for care and risk of care

Avoid legal jargon/keep short

It is all of these things that have made them what they are and these are the things that you cannot come to know

by hearsay; you can only know them if you have lived them.”

Somerset Maughan, The Razor’s Edge (Introduction), 1944.

To Conclude

“ …follow the counsel of Aristotle, to speak as the common people do, to think as wise men do; and so should every man understand him, and the judgment of wise men follow him.”—

Roger Ascham (1515-1568)